Appointment Form Only Steps to obtain an Appointment: Complete the Personal Information Sheet Entirely The Personal Information Sheet is used to obtain information necessary to establish an appointment with ( MLIC ) and/or its affiliate SafeGuard DHMO. The application on pages 2 and 3 must be completed in its entirety as applicable. If you are requesting an appointment for only the producer, then only the producer fields need to be completed. If the request for appointment includes the agency, all fields need to be completed. Page 4 must be executed by appropriate parties. Page 5, the Disclosure/Authorization form, must be executed by the appointment applicant. Pages 6 and 7, the HIPAA Business Associate Agreement, must be executed by appointment applicant who will be involved in the sale of Dental or Long-Term Care products. The applicant must be licensed in the state for which the appointment is being requested. When do you request an appointment? For the states listed below (pre-appointment), a producer must be licensed and appointed with MLIC and/or SafeGuard Health Plans, Inc. prior to the customer application being executed. Pre-Appointment States: Florida Montana Indiana Oregon Kansas Pennsylvania Louisiana Puerto Rico Missouri For all other states, the appointment request must be made no later than MLIC s receipt of the customer application. Mail: Service Delivery Center Attn: Corporate Licensing & Registration 500 Schoolhouse Road Johnstown, PA 15904 Fax: 908-552-2444 Email: CLR_Institutional@metlife.com This form cannot act as an authorization to assign commissions. 1
Appointment Form Only You are requesting an appointment with ( MLIC ) and/or its affiliate. Please check the appropriate coverage(s) for which you are requesting an appointment: MLIC Group Life/Health/Disability/MetLife Dental MLIC Group Long-Term Care P&C*(contracting required before app) Safeguard DHMO (available only in CA, FL and TX) Please check which is applicable: Producer Agency Both Section I Producer Please Type or Print Clearly Producer s Name (last name first) Birth Date Social Security Number Producer s E-Mail Address Business Phone Business Fax Business Street Address Required City, State Zip Code Resident Street Address Resident City, State Zip Code Section II Agency Principal Officer s Name Social Security Number State License Number Agency Name Agency Tax I.D. Number Business Phone Business Fax Business Street Address Required City, State Zip Code Business P.O. Box if applicable P.O. Box City, State Zip Code Section III Licensing** Producer Resident State License Number Agency Resident State License Number Producer Non-Resident State License Number(s) Agency Non-Resident State License Number(s) * For P&C appointments, please contact MAH Contracting (800) 638-3012 / MAHSalesSupport@metlife.com. ** There is no licensing requirement for the sale of DHMO products in California. 2
Appointment Form Section IV Background Information (Attach a written explanation, including date of event and discharge, for yes answers.) Yes 1. Do you have any prior affiliation with MLIC, MetLife Investors, MetLife Tower (formerly General American), or any of their affiliates? If yes, please indicate which company 2. Are you covered under your company's Errors and Omissions (E&O) policy? If not, attach the declaration page of your E&O policy. 3. Have you ever been convicted of any felony? If said felony conviction was related to dishonesty or breach of trust, have you received, subsequent to such conviction, written consent from an authorized insurance regulator that you may be employed in the insurance industry? If yes, attach a copy of such consent. 4. Has FINRA or any Federal or state regulatory agency ever: (a) found you to have made a false statement or omission or been dishonest, unfair, or unethical? (b) found you to have been involved in a violation of investment- OR insurance-related statutes or regulations? (c) found you to have been a cause of an investment- OR insurance-related business having its authorization to do business denied, suspended, revoked, or restricted? (d) entered an order against you in connection with investment- OR insurance-related activity? (e) denied, suspended, or revoked your registration or license or otherwise prevented you from associating with an investment- OR insurance-related business, or disciplined you by restricting your activities? (f) revoked or suspended your license as an attorney, accountant, or federal contractor? 5. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud? 6. Have you ever been or are you currently the subject of an investment-related, insurance-related, or consumerinitiated complaint? 7. Have you ever been discharged or permitted to resign because you were accused of: (a) violating investment- OR insurance-related statutes, regulations, rules or industry standards of conduct? (b) fraud or the wrongful taking of property? 8. Have any contracts that you held with any insurance companies been cancelled for cause (not including productivity)? 9. Has any policy or application for errors and omissions insurance on your behalf ever been declined, canceled, or renewal refused? 10. Have you ever had any of the following: sought protection from creditors, declared bankruptcy, been subject to an assignment for the benefit of creditors, had a lien or judgment, had a creditor charge off an account/payables as bad debt or uncollectible, or had any other problems in your credit history? 11. Are you under any legal order/judgment to make monetary payments to another person or business entity or have you ever had your wages garnished? No 3
Acknowledgement and Authorization I hereby certify that I have read and understand the items on this appointment form and that my answers are true and complete to the best of my knowledge. I have been advised that MLIC and/or its affiliates (collectively MetLife ) may conduct investigations in connection with my request to represent Metlife in the solicitation of certain products. I authorize an inquiry to be made of all sources deemed appropriate by Metlife for the purpose of obtaining information concerning my business practices and ethics, background, credit history, and financial status, including, but not limited to, my record, if any, on file with the FINRA Central Records Depository. Any information that MetLife may obtain about me will be treated as confidential and may be shared with the appointing general agent, if necessary. I release the broker/dealer and/or its agents and any person or entity, which provide information pursuant to this authorization, from any and all liabilities, claims or lawsuits in any matter related to the information obtained from any and all of the above referenced sources used. I understand that no right to commission or other compensation shall arise or exist until I have been appointed and all due diligence successfully approved. If I am approved, I shall accept as full compensation for all services to be performed by me, the compensation provided in the applicable commission and compensation schedule as issued, substituted or changed. As an appointed producer, I shall observe and be bound by the rules of MetLife. FAIR CREDIT REPORTING ACT - As part of its regular procedures, MetLife may obtain an investigative consumer report. It may deal with character, reputation, personal traits and life style. It may involve personal interviews with friends, neighbors and associates. I understand I have the right to make, within a reasonable amount of time, a written request for details on the name and address of the agency making the report. I further understand that depending on the state law, subjects of an investigative consumer report may have the right to: 1) request that they be interviewed in connection with the making of the report; and 2) receive a copy of the report, upon request. My signature below constitutes my agreement and authorization to above. I understand that if any of the material information I provided is found to be incorrect or incomplete, MetLife may at its discretion not appoint and/or contract with me or terminate my appointment and/or contract. I agree to conduct my business in accordance with applicable laws and standards set forth by MetLife. Individual: Printed Name Signature Date If Agency, Company Officer Please Sign Here: Printed Name Signature Date 4
MetLife Institutional U.S. Business Sales and Broker Compensation Services Disclosure By this document, on behalf of itself and its affiliates (collectively MetLife ) discloses to you that a consumer report or an investigative consumer report containing information as to your character, general reputation, personal characteristics and mode of living, is part of the process of our consideration of your application to become licensed or appointed to sell insurance and/or other products or to become registered with the Financial Industry Regulatory Authority. A consumer report or an investigative consumer report may be secured as part of a pre-appointment background investigation and at any time during your appointment with MetLife. Should an investigative consumer report be requested, you will have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Acknowledgment and Authorization I acknowledge receipt of the above disclosure by MetLife, that a consumer report or an investigative consumer report may be obtained by it as part of the process of its consideration of my application to become licensed or appointed to sell insurance and/or other products or to become registered with the Financial Industry Regulatory Authority. A consumer report or an investigative consumer report may be secured as part of its pre-appointment background investigation, and at any time during my appointment with MetLife. I authorize the procurement of such consumer reports by MetLife for the purposes disclosed to me. If I am appointed to sell MetLife products, this authorization will remain on file and will serve as an on-going authorization for MetLife to procure such consumer reports at any time during my appointment. I hereby authorize MetLife to query my record, if any, on file with the Financial Industry Regulatory Authority. Signature of Applicant: Printed Name of Applicant: SSN of Applicant: Date: Witness Signature: Printed Name of Witness: 5
HIPAA Business Associate Agreement This Agreement is made between METROPOLITAN LIFE INSURANCE COMPANY ( MetLife ) and the party identified below as the producer ( Producer ). WHEREAS, MetLife and Producer have one or more agreements in place (collectively, the Contract ) whereby Producer agreed to provide certain services for MetLife which may involve the use and/or disclosure of Customer Information and Protected Health Information ( PHI ) as defined below, and whereby Producer may have access to certain information about individuals who have applied for or are covered by an insurance product underwritten by MetLife; and WHEREAS, MetLife and Producer desire to protect the confidentiality of any Customer Information or PHI disclosed to Producer pursuant to the Contract and to satisfy requirements of the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) and as amended by the Health Information Technology for Economic and Clinical Health Act ("HITECH Act"), NOW, THEREFORE, MetLife and Producer hereby agree as follows: 1. Capitalized terms not defined herein that are defined in the Contract shall have the meanings ascribed to them in the Contract. 2. Producer agrees to treat all information about individuals who enroll, apply for or purchase MetLife s products or services that Producer may have or may obtain in connection with its obligations under the Contract ( Customer Information ) as confidential. Customer Information may include, but is not limited to, an individual s name, address, social security number, and any financial or health information relating to the individual. Producer may use Customer Information only for the purpose of fulfilling its obligations under the Contract and Producer may not disclose Customer Information to anyone other than the individual to whom the information relates, except as required for Producer to fulfill its obligations under the Contract or as otherwise directed by MetLife, or except as expressly required by law. Producer must also ensure that Customer Information is kept in a secure manner. 3. PHI is defined as individually identifiable information that is transmitted or maintained in any medium and relates to: the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or past, present, or future payment for the provision of health care to the individual. MetLife and Producer understand that this definition of PHI includes demographic information about the individual, including names; geographic subdivisions smaller than a state (including but not limited to street addresses and ZIP codes); all elements of dates (except year) for dates directly related to an individual, including but not limited to birth date; telephone numbers; fax numbers; electronic mail (E-mail) addresses; Social Security numbers; Medical record numbers; health plan beneficiary numbers; account numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers; Web Universal Resource Locators (URLs); Internet Protocol (IP) address numbers; biometric identifiers, including finger and voice prints; full face photographic images and any comparable images; and any other unique identifying number, characteristic, or code. 4. In order to further protect the confidentiality of any PHI disclosed to or used by Producer pursuant to the Contract and to satisfy requirements of HIPAA, MetLife and Producer agree to the following with respect to any PHI received or created by Producer in providing services pursuant to the Contract, including PHI received or created prior to the effective date of the Contract ( MetLife PHI ): (a) the obligations regarding MetLife PHI contained in this Agreement shall be in addition to any other obligations contained in the Contract that apply to MetLife PHI; (b) Producer may not use or disclose MetLife PHI except to provide services pursuant to the Contract; (c) Producer shall use appropriate safeguards to prevent use or disclosure of MetLife PHI; (d) MetLife and Producer represent and warrant that their security procedures are adequate to protect and maintain the confidentiality of MetLife PHI; (e) Producer shall promptly report to MetLife any use or disclosure of MetLife PHI not permitted by this Agreement of which it becomes aware; (f) Producer shall ensure that any Agents, including any sub-contractors or Producer affiliates, that Producer may use in accordance with the Contract and to whom Producer provides MetLife PHI or who uses MetLife PHI has been approved by MetLife in writing and agrees to the same restrictions and conditions that apply to Producer Page 1 of 2
with respect to MetLife PHI pursuant to this Agreement; (g) within thirty (30) days of MetLife s request, Producer shall provide to MetLife any MetLife PHI or information relating to MetLife PHI as deemed necessary by MetLife to comply with its obligations under HIPAA to provide individuals with access to, amendment of, and an accounting of disclosures of their MetLife PHI, and Producer agrees to incorporate any amendments of the MetLife PHI as requested by MetLife; (h) Producer agrees to make its internal practices, books, and records relating to its use or disclosure of MetLife PHI available to the Secretary of the United States Department of Health and Human Services at his/her request to determine MetLife s compliance; (i) Producer agrees that upon termination of the Contract it will, if feasible, return or destroy all MetLife PHI it maintains in any form and retain no copies, and if such return or destruction is not feasible, Producer agrees to extend the protections of this Agreement to the MetLife PHI beyond the termination of the Contract and for as long as Producer has MetLife PHI, and further agrees that any further use or disclosure of the MetLife PHI will be solely for the purposes that make return or destruction infeasible; (j) Producer agrees that it will not disclose MetLife PHI, other than enrollment information, to an employer or plan sponsor, unless the employer or plan sponsor has taken the steps required by HIPAA to permit disclosure to the employer or plan sponsor; (k) Producer may use or disclose MetLife PHI to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law, and only to the extent that such use or disclosure complies with any applicable HIPAA requirements relating to uses and disclosures required by law; and (l) Producer shall (1) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of any electronic MetLife PHI that Producer creates, receives, maintains, or transmits on behalf of MetLife; (2) ensure that any agent of Producer, including any subcontractor or Producer affiliate to whom Producer provides electronic MetLife PHI, agrees to implement reasonable and appropriate safeguards to protect electronic MetLife PHI; and (3) report to MetLife any security incident related to electronic MetLife PHI of which Producer becomes aware. 5. Producer agrees and acknowledges that it is directly subject to HIPAA as amended by the HITECH Act, including its provisions relating to security and privacy of PHI as well as its enforcement and penalty provisions. Producer agrees that it will: (a) comply with all applicable security and privacy provisions of HIPAA as amended by the HITECH Act and as it may be amended from time to time; (b) not act in any way to interfere with or hinder MetLife's ability to comply with HIPAA as amended by the HITECH Act and as it may be amended from time to time; and (c) notify MetLife within five (5) business days of discovering a breach as that term is defined in Section 13400 of the HITECH Act at the following e-mail address: securitybreach@metlife.com 6. In the event Producer learns of a pattern of activity or practice of MetLife that constitutes a material breach or violation of its obligations relating to PHI under the Agreement, Producer will take reasonable steps to cure the breach or end the violation. If such steps are unsuccessful, Producer will terminate the Agreement, if feasible, or, if termination is not feasible, report the problem to the Secretary of the Department of Health and Human Services ( HHS ). 7. If Producer conducts in whole or part electronic transactions on behalf of MetLife for which HHS has established standards, Producer will comply, and will require any subcontractor, vendor, or agent it involves with the conduct of electronic transactions to comply, with each applicable requirement of the Electronic Transactions Rule at 45 C.F.R. Part 162. Producer / Agency By: Printed Name: Joseph Heaney Title: Vice President Date: September 12, 2016 Printed Name: Signature: SSN / TIN:_ Date: Page 2 of 2